DAR File No. 28734

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-11

Podiatry Services

NOTICE OF PROPOSED RULE

DAR File No.: 28734
Filed: 05/15/2006, 03:20
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to clarify podiatry services policy and to implement it in rule pursuant to Subsection 26-18-3(2)(a).

Summary of the rule or change:

In the reenacted version of Rule R414-11, there is more detail regarding covered services than found in the repealed rule. The new rule also places limitations on services not found in the repealed rule, and includes all limited services under one section. In addition, the repealed rule specifies podiatry services in nursing homes, while the new rule states general service coverage in nursing homes and specifies service limitations. At the state's option, several limited services in the old rule are now listed as noncovered services in the new rule. References to medical necessity and utilization control found in the old rule no longer exist in the new rule. Further, prior authorization criteria found in the old rule does not exist in the new rule because the criteria is already referenced in Rule R414-1. The old rule specifies reimbursement procedure codes while the new rule specifies reimbursement criteria and methodology for podiatry services. Finally, the new rule is updated to reflect the copayment policy for a non-exempt Medicaid client, which is $3 for each podiatry visit.

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3, and 42 CFR 440.60

Anticipated cost or savings to:

the state budget:

There is an annual savings of $1,156 to the state general fund and $2,844 of federal funds as a result of this rulemaking.

local governments:

There is no budget impact to local governments as a result of this rulemaking because there is no funding from local governments for podiatry services.

other persons:

There is an aggregate cost of $4,000 to other persons resulting from the increase in copayment from $2 to $3 for recipients.

Compliance costs for affected persons:

There is a $5 compliance cost per recipient based on the estimate of 5 visits per year by a single client. In addition, there are compliance costs to podiatrists who are unable or choose not to collect payments from recipients; however the amount is variable for each provider.

Comments by the department head on the fiscal impact the rule may have on businesses:

There should be no significant fiscal impact on regulated businesses as a result of this rule. David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Craig Devashrayee or Don Hawley at the above address, by phone at 801-538-6641 or 801-538-6483, by FAX at 801-538-6099 or 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov or dhawley@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/03/2006

This rule may become effective on:

07/11/2006

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-11. Podiatry Services.

[R414-11-0. Policy Statement.

A. Podiatry services are available to eligible Medicaid recipients, and may be performed by a physician, osteopath or podiatrist as specified by the respective professional license.

B. Podiatric services include the examination, diagnosis and treatment of the human foot through medical, mechanical or surgical means. Podiatric service may be provided to Medicaid recipients when the recipient has a foot problem that causes:

1. difficulty walking or inability to walk;

2. painful or distressing impairment which limits independent function; or

3. crippling.

C. Reasonable and necessary diagnosis and treatment of symptomatic conditions such as osteoarthritis, bursitis (including bunion), tendinitis,"and other related conditions, "that result from, or are associated with, partial displacement of foot structures are covered services.

D. Surgical correction in the subluxated foot structure that is an integral part of the treatment of a foot injury is a benefit of the Medicaid program. Surgical correction undertaken to improve the function of the foot or to alleviate an associated symptomatic condition is also a covered service.

R414-11-1. Authority and Purpose.

A. Authority. Medicaid podiatry services are authorized under the provisions of 42 CFR 440.225 and 42 CFR 440.60. The Medicaid program is designed to provide services within financial limitations.

B. Purpose. The purpose of the program is to increase the functioning ability of the Medicaid patient.

R414-11-2. Definitions.

A. The "practice of podiatry" means the examination, diagnosis, or treatment medically, mechanically or surgically of the ailments of the human foot.

B. The medical term "subluxation" means a partial or complete dislocation.

C. The medical term "pes planus" means flatfoot.

D. "Retroactive eligibility" means that if payment for past medical expenses is requested, and eligibility exists, retroactive medical assistance may be approved.

R414-11-3. Eligibility Requirements/Coverage.

A. Podiatry services are available to children age 20 and younger and to pregnant adults. A more limited scope of services is available to adults age 21 and older as described in the Utah Medicaid Provider Manual.

B. Retroactive eligibility (See R414-11-8(D) below).

R414-11-4. Program Access Requirements.

The podiatry services are available to children age 20 and younger and pregnant adults. A more limited scope of services is available to adults age 21 and older as described in the Utah Medicaid Provider Manual.

R414-11-5. Service Coverage.

A. Procedures determined to be appropriate for the podiatry program are identified by CPT-4 codes found in the Health Common Procedure Coding System (HCPCS). These procedures include:

1. foot incision;

2. foot excision;

3. repair, revision or reconstruction;

4. surgery;

5. nail treatment;

6. laboratory procedures; and

7. radiology.

B. Laboratory procedures necessary for diagnosis and treatment of the patient may be performed by the podiatrist in the office when appropriate equipment is available. Laboratory services provided by an independent laboratory or hospital outpatient laboratory, on the order of a podiatrist, must be billed directly by the laboratory.

C. Treatment of a fungal (mycotic) infection of the toenail is a Medicaid benefit in the following circumstances:

1. There is clinical evidence of mycosis demonstrated by;

a. inflammation;

b. infection;

c. Erythema (redness of the skin due to congestion of capillaries); or

d. there is marked limitation of ambulation.

D. Nursing Home Care:

Medicaid recipients who reside in a nursing home may receive benefits from the podiatry program. Some of the benefits include:

1. excision of nail or nail matrix;

2. removal of partial or complete ingrown or deformed nails;

3. surgical procedures;

4. radiology procedures;

5. laboratory procedures;

6. the cutting or removal of corns, warts, callouses or nails of patients who are at risk due to complications from certain diseases such as diabetes, arteriosclerosis, or Buerger's Disease;

7. reasonable and necessary diagnosis and treatment of symptomatic conditions such as osteoarthritis, bursitis (including bunion), tendinitis, which result from or are associated with partial displacement of foot structures; or

8. surgical correction in the subluxated foot structure which is an integral part of the treatment of a foot injury, or if it is undertaken to improve the function of the foot or to alleviate an associated symptomatic condition.

E. Medical Supplies

1. Shoes are a Medicaid benefit only when:

a. attached to a brace or prosthesis; or

b. especially constructed to provide for a totally or partially missing foot.

2. Supplies and materials used by the podiatrist over and above those usually included for the surgery procedure may be billed separately. The materials provided must be listed.

3. Supplies for surgery performed in the office rather than a surgical center or outpatient hospital are a benefit of this service.

R414-11-6. Standards of Care.

A. The services must be considered under accepted standards of medical practice to be a specific and effective treatment for the recipient's condition.

B. The services must be:

1. of a level of complexity and sophistication, or the condition of the recipient must be such that services required can be safely and effectively performed only by a qualified podiatrist. To constitute podiatry, a service must, among other things, be reasonable and necessary to the treatment of the patient's illness. If the patient's expected health benefit would be insignificant in relation to the extent and duration of the patient's podiatry service, it would not be considered reasonable and necessary.

2. reasonable with regard to the amount, frequency and duration of services.

R414-11-7. Limitations.

A. General Limitation

1. Limitations which apply to the physicians program will also apply to the services provided by a podiatrist. If prior approval is required for a procedure performed by a physician, although it relates to the foot or foot structure, it requires prior authorization in the podiatry program.

2. Podiatric services are limited to examination, diagnosis, and treatment described in service coverage R414-11-5 above.

3. A person licensed to practice podiatry may not administer general anesthesia, and may not amputate the foot.

4. Palliative care must include the specific service and must be billed by the specific service and not by using an office call procedure code.

B. Specific Limitations

1. Routine Foot Care

a. The preventive maintenance care of the type ordinarily within the realm of self care or nursing home care considered to be routine, is not covered as a podiatry service. This includes:

(1) the cutting or removal of corns, warts or callouses, unless a danger to the patient exists (for example: diabetes, arteriosclerosis or Buerger's disease);

(2) the trimming of nails (including mycotic nails), except as specifically identified in R414-11-5, Service Coverage above;

(3) the cleaning and soaking of the feet;

(4) the use of massage or skin creams;

(5) any services performed in the absence of localized illness or injury;

(6) any application of topical medication or

(7) any treatment of fungal (mycotic) infection of the toenail, except as specifically documented.

2. Nursing Home Foot Care

a. Nursing home patient foot care is limited to one visit every two months. Services in excess of this standard require prior authorization and must be documented in sufficient detail to reasonably justify the necessity of the service.

b. Foot care which may be performed for a nursing home recipient by a nursing home employee is not a Medicaid benefit.

c. The debridement of mycotic toenails is limited to once every 60 days. Exceptions will be authorized if medical necessity is documented by the patient's physician and attached to the request for prior authorization.

3. Subluxation or Pes Planus:

Further services excluded from coverage are defined as:

1. The treatment, including evaluation, of subluxations of the feet. These are structural misalignments, or partial dislocation (other than fractures or complete dislocations) of the joints of the feet which require treatment only by nonsurgical methods regardless of underlying pathology.

2. The treatment, including evaluations and the prescriptions of supporting devices, of the local condition of flattened arches (pes planus) regardless of the underlying pathology.

C. Prosthetic Devices/Shoes/Orthotics

1. A "prosthetic device" means a replacement, corrective or supportive device prescribed by a physician or other licensed practitioner of the healing arts within the scope of his practice as defined by State law to:

a. artificially replace a missing portion of the body;

b. prevent or correct physical deformity or malfunctions (including promotion of adaptive functioning); or

c. support a weak or deformed portion of the body.

2. Orthotics, metatarsal head appliances, arch supports, are not benefits of Medicaid although they may generally fit the description of a prosthetic device.

D. Additional Limitations

The following services are excluded from coverage as a Medicaid benefit:

1. shoes, orthopedic shoes or other supportive devices for the feet, except when shoes are integral parts of leg braces or a prosthesis.

2. special shoes such as:

a. mismatched shoes (unless attached to a brace);

b. shoes to support an overweight individual;

c. trade name or brand name shoes considered "orthopedic" or "corrective";

d. "athletic" or "walking" shoes;

3. shoe repair except as it relates to external modification of an existing shoe to meet a medical need, i.e., leg length discrepancy requiring a shoe build up of one inch or more;

4. internal modifications of a shoe;

5. arch supports, foot pads, metatarsal head appliances or foot supports;

6. personal comfort items and services. Comfort items include, but are not limited to arch supports, foot pads, "cookies" or other accessories, shoes for comfort or athletic shoes;

7. manufacture, dispensing or services related to orthotics of the feet;

8. devices which do not artificially replace a missing portion of the body;

9. devices which do not prevent or correct physical deformity or malfunction;

10. devices which do not support a weak or deformed portion of the body;

11. office calls, house calls, nursing home calls, billed in addition to a service. Post payment claims review will be performed.

12. Services to adults age 21 and older are more limited as described in the Utah Medicaid Provider Manual.

R414-11-8. Prior Authorization.

A. "Prior authorization" means that degree of agency approval for payment of services required to be obtained by a provider. Such approval must be obtained precedent to service being provided. Services requiring prior authorization performed in life threatening or justifiable emergency situations are an exception. Approval of emergency service can be obtained after the fact with appropriate documentation.

1. Unlisted Services

a. All procedure codes which end in 99 and some which end in 49 have the nomenclature "unlisted service or procedure." These procedures require a prior authorization. They also require a "Special Report."

b. A special report is required because the procedure is rarely provided, unusual, variable or new. The special report must include:

(1) medical appropriateness;

(2) information covering need for the procedure;

(3) time, effort, equipment necessary;

(4) complexity of symptoms;

(5) final diagnosis;

(6) pertinent physical findings;

(7) diagnostic and therapeutic procedures previously completed or expected;

(8) concurrent problems;

(9) follow-up care.

2. Service to Nursing Home Patients:

a. Prior authorization is not necessary for the following procedures in behalf of a nursing home patient:

(1) excision of nail and/or nail matrix;

(2) excision of ingrown or deformed nail for permanent removal.

b. Surgical procedures in behalf of Medicaid recipients who reside in a nursing home will be subject to post payment review and recovery if not appropriate.

c. Prior authorization is required for the debridement of mycotic toenails in excess of once every 60 days.

d. Prior authorization is required if trimming corns, warts, callouses or nails is performed for any patient with diabetes, arteriosclerosis, or Buerger's Disease, more frequently than every 60 days.

B. Criteria for Approval of Requests

Prior approval for treatment or surgery that requires prior authorization will be reviewed and approved or denied based on the following criteria:

1. Services are for treatment of medical disorders or disabilities.

2. Services are provided for those disorders that are incapacitating for the patient and are reasonable and necessary for treatment of specific medical disorders or disabilities. Removing bunions for a bedfast patient would be disallowed;

3. Services are provided with the expectation that the condition under treatment will improve in a reasonable and generally predictable time.

4. Services are professionally appropriate under the standard in the field, utilizing professionally appropriate methods and materials in a professionally appropriate environment.

5. Services that are requested are justified with sufficient information for approval.

C. Request for Prior Authorization Form:

This form must include the following information:

1. the diagnosis and the severity of the condition;

2. the prognosis;

3. the expected independence of the recipient or benefit of the procedures;

4. the procedure code(s);

5. the patient x-rays (if applicable);

6. adequate clinical assessment of patient needs.

All requests for prior approval must be made before the surgery or service is performed, except for recipients made retroactively eligible for Medicaid.

D. Retroactive Eligibility

When a patient is made retroactively eligible for Medicaid and services have already been rendered which require prior approval, the following procedures must be followed:

1. The recipient must present a Medicaid Identification Card (ID Card), or an Interim Verification of Eligibility Form (695) which verifies the eligibility status of the recipient and the inclusive dates of eligibility.

2. The Request for Prior Approval Form must be completed.

3. The retroactive eligibility status of the recipient and appropriate documentation of the medical need for the procedure must be stated on the Request for Prior Approval Form.

4. The date of surgery or service must be within the dates of eligibility.

E. Out-of State

1. Any Medicaid request for out-of-state medical services or travel other than those listed below, must have prior authorization from the Division of Health Care Financing. There are four areas in which a Medicaid recipient may live (adjacent to the state line) and may go to another state, as stipulated, for medical services.

2. The following border towns have been identified by the Department of Social Services, Office of Assistance Payments, and entered into the Medicaid Provider File:

a. Rich County residents may go to Evanston, Wyoming; Riverton, Wyoming; Preston, Idaho; Paris, Idaho or Montpelier, Idaho.

b. San Juan County residents may go to Cortez, Del Norte, Dolores, Durango, Grand Junction and Montrose, Colorado; or to Shiprock or Farmington, New Mexico.

c. Residents of the Snake Valley area in Millard County, (Garrison, Gandy, Burbank and Eskdale), may go to Ely, Nevada and East Ely, Nevada.

R414-11-9. Reimbursement for Podiatry Service.

A. Introduction

There are numerous procedure codes listed in the Podiatrist Provider Manual for Medicaid services. Only the listed procedure codes are reimbursable by the Medicaid Medical Information System (MMIS).

B. Office Calls

Office calls are not designated by the time involved but by the service provided. The CPT identifies the elements and services included in each level of office call or house call. Utilizing these designations, the appropriate codes are identified in the podiatry index.

C. Nursing Home Patients

All surgical procedures provided for a nursing home recipient must be medically necessary and appropriate, and may be subject to post payment review.

D. Injection Procedures

Procedure codes with the J prefix are for injections. The J codes specifically identified for podiatric use are in the Podiatry Provider Manual.

E. Laboratory Procedures

Only those laboratory procedures for which the podiatrist or physician has the appropriate office equipment may be billed to Medicaid. Reimbursable laboratory procedure codes are listed in the Podiatry Provider Manual.

R414-11-10. Co-payment Policy.

This section establishes co-payment policy for podiatrist services for Medicaid clients who are not in any of the federal categories exempted from co-payment requirements. The rule is authorized by 42 CFR 447.15 and 447.50, Oct. 1, 2001 ed., which are adopted and incorporated by reference.

(1) The Department shall impose a co-payment in the amount of $2 for each podiatrist visit when a non-exempt Medicaid client, as designated on his Medicaid card, receives that podiatrist service. The Department shall limit the out-of-pocket expense of the Medicaid client to $100 annually. (Co-payments for pharmacy services will continue to be limited to $5 per month.)

(2) The Department shall deduct $2 from the reimbursement paid to the provider for each podiatrist visit, limited to one per day.

(3) The provider should collect the co-payment amount from the Medicaid client for each podiatrist visit, limited to one per day.

(4) Medicaid clients in the following categories are exempt from co-payment requirements:

(a) children;

(b) pregnant women;

(c) institutionalized individuals;

(d) individuals whose total gross income, before exclusions or deductions, is below the Temporary Assistance to Needy Families (TANF) standard payment allowance. These individuals must indicate their income status to their eligibility case worker on a monthly basis to maintain their exemption from the co-pay requirements.]

R414-11-1. Introduction and Authority.

Podiatry services are authorized by 42 CFR 440.60 and include the examination, diagnosis, or treatment of the foot. Podiatry services are optional and provided in accordance with 42 CFR 440.225.

R414-11-2. Definitions.

In this rule, "Subluxation" means a structural misalignment or partial dislocation of a joint or joints in the feet.

R414-11-3. Client Eligibility Requirements.

Podiatry services are available to categorically and medically needy individuals.

R414-11-4. Service Coverage.

(1) The Department covers the following podiatry services:

(a) foot incision and drainage of simple abcess;

(b) foot skin debridement;

(c) cutting benign or premalignant lesions;

(d) treatment of nail plate;

(e) injections for ganglion cysts;

(f) foot bone excisions;

(g) walking cast, Unna boots;

(h) radiologic exam of ankle or foot; and

(i) office visits.

(2) The Department covers the following podiatry-related medical supplies and equipment:

(a) shoes attached to a brace or prosthesis;

(b) shoes specially constructed to provide for a totally or partially missing foot; and

(c) additional supplies not regularly used for office surgery procedures.

(3) Shoe repair is covered if it relates to external modification of an existing shoe to accommodate a leg length discrepancy requiring a shoe build up of one inch or more.

R414-11-5. Limitations.

(1) Service limitations that apply to physicians also apply to podiatrists.

(2) Treatment of a fungal (mycotic) infection of the toenail is limited to recipients with documented clinical evidence of mycosis that shows inflammation, infection, erythema, or marked limitation of ambulation.

(3) Podiatry services in long-term care facilities are covered with the following limitations:

(a) podiatry visits are limited to once every 60 days;

(b) debridement of mycotic toenails is limited to once every 60 days;

(c) trimming corns, warts, callouses, or nails is limited to once every 60 days;

(d) podiatry visits that include only evaluation and management are not covered;

(4) Medicaid does not cover the administration of general anesthesia and foot amputations by podiatrists.

(5) The removal of corns, warts, or callouses is limited to patients endangered by diabetes, arteriosclerosis or Buerger's disease.

R414-11-6. Non-Covered Services.

(1) The following preventive or routine foot care services are not covered:

(a) the trimming, cutting, clipping, or debridement of nails outside of long-term care facilities;

(b) hygienic and preventive maintenance care, such as cleaning and soaking of the feet, the use of massage or skin creams to maintain skin tone of either ambulatory or bedfast patients, and any other service performed in the absence of localized illness or injury;

(c) any application of topical medication;

(2) Supportive devices that include arch supports, foot pads, foot supports, orthotic devices, or metatarsal head appliances are not covered.

(3) The following subluxation services are not covered:

(a) surgical correction of a subluxated foot structure, or surgical procedures performed to improve foot function and alleviate symptomatic conditions;

(b) treatment that includes evaluations and prescriptions of supporting devices, and the local condition of flattened arches regardless of the underlying pathology.

(4) Internal modification of a shoe is not covered.

(5) Shoes or other supportive devices for the feet that are not an integral part of a leg brace or prosthesis are not covered.

(6) Special shoes are not covered. These include:

(a) mismatched shoes (unless attached to a brace);

(b) shoes to support an overweight individual;

(c) "orthopedic" or "corrective" trade name or brand name shoes; and

(d) "athletic" or "walking" shoes.

(7) Personal comfort items such as "cookies" or other comfort accessories are not covered.

R414-11-7. Reimbursement for Podiatry Services.

(1) Reimbursement for services is limited to one podiatry office visit per day.

(2) A podiatrist may bill for laboratory procedures necessary for diagnosis and treatment of the patient if equipment necessary for the laboratory procedure is available in the podiatrist's office. Laboratory services requested by a podiatrist but provided by an independent laboratory or hospital outpatient laboratory must be billed directly by the laboratory.

(3) Palliative care is included in the specific service and must be billed by that service only, not through the use of an office call procedure code.

(4) Payments are based on the established fee schedule unless a lower amount is billed. The amount billed cannot exceed usual and customary charges to private pay patients. Fees are established by discounting historical charges, and by professional judgment to encourage efficient, effective and economical services.

R414-11-8. Copayment Policy.

(1) The Department requires a copayment in the amount of $3 for each podiatry visit when a non-exempt Medicaid client as designated on his Medicaid card, receives a podiatry service. Medicaid limits the out-of-pocket expense of the Medicaid client to $100 annually, which is a total aggregate cost for all Medicaid services.

(2) Medicaid deducts the copayment amount, limited to one amount per day from the reimbursement paid to the provider for each podiatry visit.

(3) The provider should collect the copayment amount from the Medicaid client for each podiatry visit.

(4) Medicaid clients in the following categories are exempt from copayment requirements:

(a) children;

(b) pregnant women;

(c) institutionalized individuals; and

(d) individuals whose total gross income, before exclusions or deductions, is below the Temporary Assistance to Needy Families (TANF) standard payment allowance.

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [October 2, 2002]2006

Notice of Continuation: November 3, 2004

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Craig Devashrayee or Don Hawley at the above address, by phone at 801-538-6641 or 801-538-6483, by FAX at 801-538-6099 or 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov or dhawley@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.